Posted on
Sunday 30 March 2014

"I don’t want to be lying on my deathbed and asking, ‘What was all that about?’"

attributed to Marlon Brando

We’re approaching the one year anniversary of the release of the DSM-5, an event shrouded in confusion, contention, and disappointment. I don’t recall many of us paying very much attention to it before the summer of 09, though the revision process was by then a decade old. In June 2009, the leaders published something of a state of the revision Commentary in the AJP. By then, the chairs had been appointed [April 2006], the Task Force [July 2007] and Workgroups [July 2008] populated, and work was underway. Although there had been an extensive series of symposia in the interim, this Commentary was little changed from their earlier book, A Research Agenda for the DSM-V, published in 2002:

While a lot of this Commentary is about their processes of the previous decade, there are several things of note. They reviewed the creation of the DSM-III from the Feighner criteria and the RDC, attributing it all to the influence of Robins and Guze, the neoKraepelinians. They talked about a 1980 expectation that subsequent basic research would validate those categories – something that hadn’t happened. They pointed to the high rates of comorbidity, the heavy use of the NOS designation, the fact that medications were not diagnosis specific, and the failure to find biological markers for the categories. They saw these things as evidence that it was time for a change in direction – a paradigm shift. Their solutions included [as always] finding the missing biomarkers, including biological correlates with the diagnoses, and adding "dimensional" elements to the diagnostic system – "cross-cutting dimensions."

The single most important precondition for moving forward to improve the clinical and scientific utility of DSM-V will be the incorporation of simple dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries. Thus, we have decided that one, if not the major, difference between DSM-IV and DSM-V will be the more prominent use of dimensional measures in DSM-V.

Neither Dr. Spitzer [DSM-III, DSM-IIIR] nor Dr. Frances [DSM-IV] were mentioned in this article even in passing. Perhaps Dr. Spitzer’s ommission had to do with his earlier calling the DSM-V Task Force out for its secrecy policies, but the reason for their omission of Dr. Frances and their general negativity towards the DSM-IV wasn’t clear [maybe they had a premonition]. Another thing, in spite of heavily referencing elsewhere in the article, this comment is reference-free:

… we have come to understand that we are unlikely to find single gene underpinnings for most mental disorders, which are more likely to have polygenetic vulnerabilities interacting with epigenetic factors [that switch genes on and off] and environmental exposures to produce disorders.

Then, later that month, Dr. Frances spoke up. If you don’t know the story of why, it’s worth your time to read Gary Greenberg’s later article in Wired that tells the story, Inside the Battle to Define Mental Illness:

Their ambition to achieve a paradigm shift when there is no scientific basis for one.

Their failure to provide clear methodological guidelines on the level of empirical support required for changes.

Their lack of openness to wide scrutiny and useful criticism.

Their inability to spot the obvious dangers in most of their current proposals.

Their failure to set and meet clear timelines.

The likelihood that time pressure will soon lead to an unconsidered rush of last-minute decisions.

This is the first time I have felt the need to make any comments on DSM-V. Even when the early steps in the DSM-V process seemed excessively ambitious, secretive, and disorganized, I hoped that I could avoid involvement and believed that my successors deserved a clear field. My unduly optimistic assumption was that the initial problems of secrecy and lack of explicitness would self-correct and that excessive ambitions would be moderated by experience. I have decided to write this commentary now only because time is running out and I fear that DSM-V is continuing to veer badly off course and with no prospect of spontaneous internal correction. It is my responsibility to make my worries known before it is too late to act on them…

Notice that in the Commentary and in Dr. Frances’ article warning of the pitfalls in the trajectory of the DSM-5 Task Force, so far we have heard next to nothing about any of the diagnostic categories themselves. The Co-Chairs are focused on their disappointments or dis-satisfactions with previous efforts. Dr. Frances is worried about the push for a paradigm shift, and the way they’re approaching the revision itself. But the actual diagnoses themselves are still not on the front burner. The APA response came less than a week later from the President of the APA [Alan Schatzberg], the APA Medical Director [James Scully], and the DSM-V Co-Chairs [David Kupfer and Darrel Regier]. They hardly took Frances’ critique as constructive criticism [to say the least]:

Finally, Dr. Frances opened his commentary with the statement, “We should begin with full disclosure.” It is unfortunate that Dr. Frances failed to take this statement to heart when he did not disclose his continued financial interests in several publications based on DSM-IV. Only with this information could the reader make a full assessment of his critiques of a new and different DSM-V. Both Dr. Frances and Dr. Spitzer have more than a personal “pride of authorship” interest in preserving the DSM-IV and its related case book and study products. Both continue to receive royalties on DSM-IV associated products. The fact that Dr. Frances was informed at the APA Annual Meeting last month that subsequent editions of his DSM-IV associated products would cease when the new edition is finalized, should be considered when evaluating his critique and its timing.

That’s the low point of this story for me – a school playground bully response that has no place in any serious dialog. Dr. Frances shook it off, turned the other cheek, and moved on. I can’t seem to. I hear that nastiness in everything since. But I do want to mention something else from their article.

As documented in the recent American Journal of Psychiatry article [Regier, et al., 2009], the use of dimensional assessments to reconceptualize psychopathology represents the most practical and evidence-based way of moving our field forward. Recent studies underscore the readiness of clinicians in both primary care and specialty mental health settings to adopt dimensional instruments on a routine basis [Duffy et al., 2008, Trivedi et al., 2006].

The articles mentioned hardly represent any groundswell for "dimensional" diagnoses. Two are from Dr. Regier himself and the other is from the STAR*D team – Dr. Trivedi, long obsessed with measurement based care. Like the Commentary, this response is heavily focused on the Dimensional Diagnosis concept.

Literally, on the next day, Dr. Spitzer weighed in, again commenting on the closed shop way things were proceeding. By this point, the field trials were eminent, yet no one outside the Task Force knew what was even being tested, or how. By July of 09, the DSM-V/5 Revision had moved from esoterica in the background to the front page; the APA and the DSM Task Force had become entrenched in a bunker mentality; and the rest of the world was about to enter the dialog…

The single most important precondition for moving forward to improve the clinical and scientific utility of DSM-V will be the incorporation of simple dimensional measures for assessing syndromes within broad diagnostic categories and supraordinate dimensions that cross current diagnostic boundaries.

This reminds of a little exercise in an art historiography seminar. We were required to print copies of eight individual works of art in one genre from one period, then rearrange and group them differently according to different art theories while expounding on the differences and similarities. What would creating a system of supraordinate dimensions that cross different art forms look like ? My ex-husband once said that if someone could develop an instrument that could measure how close a painting came to reality, then there would be a way to reliably judge the quality of a painting and rank paintings in artistic value accordingly. I said, “So much for painting then, we have the camera.” He could be diagnosed with an engineering pathology and a omorbid aesthetic deficiency, but I think he and the key people on the DSM-5 committes have the same syndrome.

I can’t tie what I just said into a linear argument, in fact, I could not make a linear argument to save my life and find them to be of limited value in most conversations, but I think you’ll all get my drift here.

What is the point of the DSM-5, really? They can prescribe anything they want now, haven’t shown any real interest in studying the drugs they do prescribe, appear to have no interest in how the drugs are affecting patients beyond addressing the symptoms that they used to to give a patient a lable, andhave made it clear that all they want to know about a patient is where to throw the dart using an instrument that a monkey could use to press the buttons to dispense the drugs. They have no instruments for mental health. I suspect that the KOLs are working on ways to make themselves the real scientists of psychiatry so they can replace the rest with low paid nurses; because all they really need to be on top of their hill of beans getting a bigger share of the pie and having the world at their feet is talking a good game to get grant money and payola while the entire apparatus of research and development rests on them and fails us all.

These icons of mental illness are made of wood. They aren’t going to be real boys, no matter how many rubes they can convince otherwise, It’s a wonder they can see face anyone, their noses have gotten so long.

My reaction to Sandra’s idea of disbanding the field, startled me. If anyone had told me when I started reading your blog, Dr. Nardo, that I would ever feel like saving psychiatry I wouldn’t have believed it. I’m hoping a critical mass of critical psychiatrists can lobby to reign it in. There are so many developments in the field now from professionals and lay persons that are promising a better paradigm.

Zygmunt Bauman talks about modernity as a “global factory of human waste,” by which he means the waste of human talent, intelligence, creativity, and passions. Contemporary psychiatry is a diminishing machine. People deserve better and could do much better without it. For the love of humanity, this profession needs to be put in check so that humans the human psyche can continue to evolve.

1 April 2014 Health Insurance Times (Dubuque, Iowa) A health care industry thinktank, US Health Insurance Consortium on Cost, advocates replacing psychiatrists and other doctors with vending machines to prescribe and dispense antidepressants.

“We believe this will cut the cost of psychiatric services significantly,” Uli Arnowsky, spokesperson for USHICost, said. “Our studies show the diagnosis and prescription process can be automated, with no loss in quality of care. Specialist costs are just not necessary for this type of treatment, and psychiatrists are overworked anyway.”

USHICost based its Psychiatric Diagnostic Screening Questionnaire (PDSQ) on the new psychiatric diagnostic manual DSM-5 and research by Drs. David J. Kupfer and Robert D. Gibbons. It plans to make the PDSQ available online to health plan members. Answers would be captured in a database and analyzed to produce a recommendation for a prescription. A psychiatric nurse reviews the recommendations and authorizes the prescription, which is then attached to the patient’s electronic medical record.

Vending machines, in convenient medical center locations and on a secure network, would be stocked with the most common generic antidepressants.

“We prefer the generics,” Arnowsky said. “They’re part of the cost-cutting. Our studies show they’re just as effective as the name-brand drugs.”

According to Arnowsky, to get a prescription filled, a patient would input a health plan ID and a password at a vending machine. The machine would look in the database, dispense the authorized prescription, and charge the co-pay to a credit card on file in the patient’s health plan record.

“We really like the way this system keeps electronic medical records, too,” Aronowsky said. “It’s a win-win-win for all concerned.”

Patients reporting side effects would be advised to see their doctors, who could then adjust the prescription if needed.

“There’s a lot of trial and error in prescribing antidepressants already,” he said. “This system is no more error-prone than present prescribing practices. In fact, we put fuzzy logic in the system to rotate prescriptions among the antidepressants, because we’ve found doctors prescribe them in an almost random fashion. We built the human element right into the system — it thinks just like a doctor about these drugs.”

He stated that USHICost’s studies had shown diagnosis by PDSQ was at least as accurate as by doctors, including psychiatrists. “This will take a big burden off primary care physicians, too, who are bearing the brunt of prescribing antidepressants,” he noted.

Any news writer clutching pearls over young people throwing a bunch of psychoactive prescription drugs from their parents’ medicine cabinets into a big bowl, qua spiked punch at parties, should get off the fainting couch. The kids learned by example while the media insisted that the drugs were safe and reliable— not like those nasty illicit drugs.

In fact, I’d bet experienced recreational pill poppers could tell the average KOL more about the initial effects of psychiatric medicines.

I am not saying there isn’t an oddball out there thinking vending machines for meds are a good idea; it certainly is the way business thinks. But it seems this write up was done for a laugh, nothing more.

I should have stated “prescribing and dispensing vending machines”. There already are OTC med vending machines (we have them at my workplace), and it looks like there have been trials of Rx dispensing machines in several countries but I didn’t find any recent articles on them.